10-Advance Advance Notice of Reportable Events

ADVANCE NOTICE
OF REPORTABLE EVENTS

PBGC Form 10-Advance

Approved OMB #1212-0013
Expires 03/31/2012

This form may be used by a contributing sponsor of a single-employer plan required to notify the Pension Benefit
Guaranty Corporation in advance that a reportable event will occur.

IDENTIFYING INFORMATION
Name of Plan

Name of contributing sponsor

Name / title of individual to contact

Street address of contributing sponsor

Street address of contact

City, State, Zip

City, State, Zip

EIN of contributing sponsor

REPORTABLE EVENTS

Plan number

Telephone number of contact

Ext.

See instructions for descriptions of these events. Check all boxes that apply.

Change in contributing sponsor or controlled group

Application for minimum funding waiver

Liquidation

Loan default

Extraordinary dividend or stock redemption

Bankruptcy or similar settlement

Transfer of benefit liabilities

BRIEF DESCRIPTION

Briefly describe the pertinent facts relating to the event.

The next page lists additional information that must be submitted with this form, if not included above.

PBGC Form 10-Advance
ADDITIONAL INFORMATION TO BE FILED
Change in Contributing Sponsor or Controlled Group
Expected effective date of event
Description of the plan’s old and new controlled group
structures, including the name of each controlled group
member
Name of each plan maintained by any member of the
plan’s old and new controlled groups, its contributing
sponsor(s) and EIN/PN
Most recent audited (or, if unavailable, unaudited)
financial statements and interim financial statements
of the plan’s contributing sponsor (both old and new in
the case of a change in the contributing sponsor) and
any persons that will cease to be in the plan’s controlled
group
Liquidation
Expected effective date of event
Description of the plan’s controlled group structure
before and after the liquidation, including the name of
each controlled group member

Transfer of Benefit Liabilities
Name, contributing sponsor and EIN/PN of transferor plan
and transferee plan(s)
Explanation of the actuarial assumptions used in
determining the value of benefit liabilities (and, if
appropriate, plan assets) transferred
Estimate of the assets, liabilities, and number of
participants whose benefits are transferred
Note: To the extent this information is filed with the IRS Form
5310A, PBGC will accept a copy of that filing.
Application for Minimum Funding Waiver
Copy of the waiver application, with all attachments
Loan Default
Copy of the relevant loan documents (e.g., promissory
note, security agreement)

Name of each plan maintained by any member of the
plan’s controlled group, its contributing sponsor(s) and
EIN/PN

Due date and amount of any missed payment

Most recent actuarial valuation report for each plan in
the controlled group

Copy of any written notice of acceleration from lender

Extraordinary Dividend or Stock Redemption
Name and EIN of person making the distribution
Date and amount of cash distribution(s) during fiscal
year

Copy of any written notice of default from lender

Bankruptcy or Similar Settlement
Copy of all papers filed in the relevant proceeding,
including, but not limited to, petitions and supporting
schedules
Last date for filing claims, if known

Description, fair market value, and date or dates of any
non-cash distributions

Name, address and phone number of any trustee,
receiver or similar person

Statement as to whether the recipient was a member of
the plan’s controlled group

Most recent actuarial valuation report for each plan in the
controlled group
Description of the plan’s controlled group structure,
including the name of each controlled group member
Name of each plan maintained by any member of the
plan’s controlled group, its contributing sponsor(s) and
EIN/PN